Burns - Resuscitation, Referral and Retrieval

1. Burns - Resuscitation, Referral and Retrieval • Ken Harrison • Careflight • Westmead Hospital NSW • Welcome

2. Disclosed Interests • Financial - nil

3. Disclosed Interests • Financial - nil • Emotional - plenty

4. Burns and EBM • There is no Metaanalysis • There is one Randomised trial (it showed more deaths in the trial group) • There are precious few case controlled trials (all from >25 years ago) • There are lots of case reports/audits/ideas/suggestions

5. Types of Burn Injury • Thermal • Scalds • Flame • Contact • Cold • Electrical • Chemical • Radiation • ‘Medical’ Skin loss e.g. Toxic Epidermal Necrolysis

7. Incidence of Burn Injuries • 100 severe burns requiring resuscitation per year – half of these are children • 20 - 30 deaths/year in Australia • 50% firstly admitted to non-specialist units • Incidence falling • Prognosis improving

8. Scald Injury

10. Burns • Resuscitation • First Aid • Primary Survey • Fluids • Analgesia • Dressings • Retrieval • Disasters

11. History • Time of burn • Flame/scald/chemical/electrical • Enclosed space • Associated trauma

12. First Aid • Cool Running Water • For about 20mins ?? • Time = Tissue

16. First Aid • Cool Running Water • For about 20mins ?? • Time = Tissue • But once the heat has gone, warm them up.

17. Waiting for Emma • I was sitting in my usual restaurant when my attention was drawn by the hizz and steam as a plate of sizzling oriental steak was paraded aloft with style towards a young couple dining alone. • As the waiter reached the table, he tripped or faltered and the entire contents of the plate fell onto the young womans chest.

18. Waiting for Emma • She screamed in agony and as my hand flew to cover my mouth in horror, I observed a man sitting 2 tables away from her immediately arise, stride to her table, picking up a bottle of Moet from the table in between

19. Waiting for Emma • and pulling her blouse away from her chest, he proceeded to empty the champagne onto her ample clevage with immediate relief on her part.

20. First Aid • Time is Tissue

21. Burns • Resuscitation • First Aid • Primary Survey • Fluids • Analgesia • Dressings • Retrieval • Disasters

22. Primary Survey A-Airway • Airway Burns • Voice change, stridor • Sooty sputum • Facial burn • Singed nasal hair

25. Upper Airway Injury • Sit up • Avoid excessive resuscitation fluids • Early ophthalmic referral • No role for steroids • tie/wire/tape/

26. What is an inhalation injury? • Damage caused by aspiration of superheated gases, steam, hot liquids or noxious products of combustion • Damage may be to upper or lower airway or both • If the event was associated with an explosion, there may also be “blast” injury to the lungs

27. A- continued • Intubations are not more difficult than normal if done early • But may be difficult +++ later • Suxamethonium safe in first 24 hours

39. Case Report • It was a dark and stormy night • 45 year old man, had new shiny BBQ on new shiny deck. • 20+ for dinner and numerous beers • “decided” to move the BBQ under cover, due to rain, so disconected from mains gas and connected to bottled. • difficult to start - followed by bang.

40. Case Report • arrived by private car in small hospital 50 km from Sydney • obvious facial, inhalational and upper arm and torso burns • anaesthetist called immediately as he had just walked through to go to maternity

41. Case Report • He came back to ED and saw the 115kg past front rower man sitting upright in pain as preparations were being made to intubate him. • Past GA history “difficult to get the tube down”. • Lots of discussion with Burns hospital and Medical retreival

42. Case Report • Patient given 100mls/hr and analgesia • Medical retrieval drove to the hospital • Sat up in ambulance en route to burns centre • “interesting fibreoptic intubation ” at burns centre

43. Primary Survey B - Breathing • Breathing and control of ventilation • Remember usual trauma causes of breathing problems, pneumothorax, haemothorax etc • Think about Blast vs Burnt lung • Exclude circumferential burn to chest

45. Primary Survey C - Circulation • Stop the Bleeding • Assess Circulation • BP, P, peripheral perfusion • Hypovolaemic shock at early stage will not be due to burn - suspect trauma • Large bore IV access through unburnt skin and not distal to large burns • Secure lines well

46. Mumford’s Rule of Tape • In a retrieval the amount of tape and ties used to hold in lines and tubes shall not exceed the distance between the patient and the receiving hospital, but anything less than that is acceptable

47. Harrison’s Corollary • In a retrieval no matter how you secure the ETT, when you arrive at the receiving ICU, it will be wrong • So follow Mumford’s rule

48. Parkland Formula • Parkland (Baxter) formula (1968) • Easy, simple, widely used throughout the world • 4 ml kg-1 TBSA-1 Hartmann’s over 24hrs from the time of the burn • First half given over first 8 hours • Second half over next 16 hours • No Colloid in first 24hrs • Endpoint UO 0.5-1 ml-1 kg-1 hr-1

49. Hypertonic Saline (HTS) • Restoration of intravascular volume by reabsorption of fluid from interstitial space • ?Immunomodulatory action (IL 1,IL10, TNF) • Ovine models of burn trauma associated with improved organ perfusion and less oedema if given early

50. 213 burns patients (65 HTS) • HTS received significantly less fluid • Fourfold increase in renal failure in the HTS gp (40.0 vs. 10. 1%) • Doubling of mortality in HTS patients (53.8 vs. 26.6%)